There is a high risk of developing HELLP syndrome in pre-eclamptic patients. Considering that she is complaining of right upper quadrant pain, a LFT should be done immediately.

The most common treatment approach is with the dopamine receptor agonists, bromocriptine, and cabergoline. Bromocriptine normalizes prolactin and decreases tumour size in 80%–90% of patients with microadenomas. Bromocriptine should be given to this patient who has developed hyperprolactinemia anovulation.

Women with hyperprolactinaemic anovulation are treated with dopamine agonists such as bromocriptine.
This patient has also developed symptoms of a low-functioning pituitary gland tumour, which bromocriptine will assist to shrink. Before starting bromocriptine, a head MRI scan should be considered to confirm the suspected diagnosis.

Clomiphene is an oestrogen receptor modulator that is selective. It works by competing with oestrogen receptors in the hypothalamus. This disrupts normal negative feedback mechanisms, causing the release of pituitary gonadotropins, particularly LH, to rise, triggering ovulation.
When the levels of gonadotropins and oestrogen are normal but the women still have ovulatory dysfunction, it is successful in inducing ovulation. In hypogonadotropic hypogonadism and hypogonadotropic hypogonadism patients, clomiphene is frequently ineffective.

Uterine blood flow increases 40-fold to approximately 700 mL/min at term, with 80 per cent of the blood distributed to the intervillous spaces of the placentae, and 20 per cent to the uterine myometrium. Weight of the uterus increases from 50–60 g prior to pregnancy to 1000 g by term.

Puerperal psychosis seems to be mainly hereditary and closely associated with bipolar disorder especially the manic type, rather than being a distinct condition with a group of classical symptoms or course. Postpartum psychoses typically have an abrupt onset within 2 weeks of delivery and may have rapid progression of symptoms. Fortunately, it is generally a brief condition and responds well to prompt management. If the condition is threatening the mother and/or baby’s safety, hospital admission is warranted. A patient can present with a wide variety of psychotic symptoms ranging from delusion, passivity phenomenon, catatonia, and hallucinations. While depression and mania may be the predominating features, it is not surprising to see symptoms such as confusion and stupor. Although the rate of incidence is about 1 in 1000 pregnancies, it is seen in about 20% of women who previously had bipolar episodes prior to pregnancy. It has not been shown to be linked with factors such as twin pregnancies, stillbirth, breastfeeding or being a single parent. However, it might be more commonly seen in women who are first-time mothers and pregnancy terminations.

The risk of recurrence is 20%. Unfortunately, there is no specific treatment guideline but organic causes should first be ruled out. First generation/typical anti-psychotics are often associated with extrapyramidal symptoms. Nowadays, atypical antipsychotics such as risperidone or olanzapine can be used along with lithium which is a mood stabiliser. As of now, there hasn’t been any significant side effects as a result of second generation antipsychotic use in pregnancy. While women are usually advised to stop breast-feeding, it might be unnecessary except if the mother is being treated with lithium which has been reported to cause side effects on the infants in a few instances. ECT is considered to be highly efficacious for all types of postpartum psychosis and may be necessary if the mother’s condition is life-threatening to herself or/and the baby. If untreated, puerperal psychosis might persist for 6 months or even longer.

The options of saying ‘in view of her age and previous problem, further pregnancies are out of the question’ and so is ‘By all means start another pregnancy and see how she feels about it. If she has misgivings, then have the pregnancy terminated.’ are inappropriate.

As mentioned earlier, considering there is a 20% chance of recurrence it is not correct to say that since she had good outcomes with her first pregnancy, the risk of recurrence is minimal.

Anti-psychotics are not recommended to be used routinely both during pregnancy and lactation due to the absence of long-term research on children with intrauterine and breastmilk exposure to the drugs. Hence it is not right to conclude that ‘if she gets pregnant then she should take prophylactic antipsychotics throughout the pregnancy’ as it contradicts current guidelines. Each case should be individualised and the risks compared with the benefits to decide whether anti-psychotics should be given during pregnancy. It is important to obtain informed consent from both the mother and partner with documentation.

Should the mother deteriorates during the pregnancy that she no longer is capable of making decisions about treatment, then an application for temporary guardianship should be carried out to ensure that she can be continued on the appropriate treatment.

The SIJ is a synovial joint. The Pubic Symphysis is a Secondary Cartilaginous

Molding allows the skull bones of the fetal head some mobility during the normal delivery of foetus as the skull changes its shape to accommodate passage through the mothers pelvis. However this does not occur in breach delivery where the skull is in circular shape. Babies born breech typically have craniofacial and limb deformations resulting from their in utero position. These babies characteristically have a long, narrow head, (“dolichocephaly” or “type 1”), with a prominent occipital shelf, redundant skin over the neck, overlapping lambdoidal sutures, and an indentation below their ears (from shoulder compression).

If the external anal sphincter is in tact then this is a 1st or 2nd degree tear. As the perineal muscles are involved this is 2nd degree tear.

The risk of developing endometrial carcinoma is less than 5% over 20 years if the endometrium shows hyperplasia without atypia.
There are 2 types of Endometrial Hyperplasia:
1. Hyperplasia without atypia*
2. Atypical hyperplasia

Major Risk Factors:
Oestrogen (HRT)
Tamoxifen
PCOS
Obesity
Immunosuppression (transplant)

There is 70% chance that a women who has had a C-section can deliver via spontaneous vaginal delivery.

First stage of the labour starts with the contractions of the uterus. With time, the no. of contractions, its duration and intensity increases. It ends once the cervix is fully dilated.

Functional closure of the ductus arteriosus is neonates is completed within the first few days after birth. It normally occurs by the 12th postnatal week. It has been suggested that persistent patency of DA results from a failure of the TGF-B induction after birth. Due to increased arterial pO2, constriction of the DA occurs. In addition to this on inflation the bradykinin system is activated with cause the smooth muscles in the DA to constrict. A decrease in the E2 prostaglandin is also an important factor as raised levels have been indicated in keeping the patency of the DA.

Genital herpes can be asymptomatic or have mild symptoms that go unrecognized. When symptoms occur, genital herpes is characterised by one or more genital or anal blisters or ulcers. Additionally, symptoms of a new infection often include fever, body aches and swollen lymph nodes.

HSV-2 is mainly transmitted during sex through contact with genital or anal surfaces, skin, sores or fluids of someone infected with the virus. HSV-2 can be transmitted even if the skin looks normal and is often transmitted in the absence of symptoms.

In rare circumstances, herpes (HSV-1 and HSV-2) can be transmitted from mother to child during delivery, causing neonatal herpes. Neonatal herpes can occur when an infant is exposed to HSV during delivery. Neonatal herpes is rare, occurring in an estimated 10 out of every 100 000 births globally. However, it is a serious condition that can lead to lasting neurologic disability or death. The risk for neonatal herpes is greatest when a mother acquires HSV for the first time in late pregnancy.

Stress incontinence is characterized by the involuntary loss of urine with increases in intra-abdominal pressure. It is the most common type of incontinence in younger women, but also occurs in older women. Key risk factors include childbirth, medications that relax the urethral sphincter, obesity, lung disease (from chronic cough), and prior pelvic surgeries. Numerous treatments are available, although few studies compare one treatment with another.

Pelvic floor muscle exercises are the mainstay of behavioural therapy for stress incontinence. Up to 38 percent of patients with stress incontinence alone who follow a pelvic floor muscle exercise regimen for at least three months experience a cure.

Routine urodynamic tests are not recommended for urinary incontinence. Surgery is reserved for refractory incontinence.

This is Linea Nigra. It occurs in 3/4 of pregnancies and is due to increased melanocyte-stimulating hormone production by the placenta. This also causes melasma and darkening of the nipples.

This patient is presenting with a severe placental abruption causing fetal death and shock in the mother. The most appropriate initial management for the patient is to treat her shock with blood transfusions and exclude or treat any coagulation disorder resulting from the abruption. Delivery also needs to be expedited to remove the dead foetus. An amniotomy is usually all that is required to induce spontaneous labour as the uterus is usually very irritable. Spontaneous labour is likely to occur in this case, where the cervix is already 4 cm dilated and fully effaced.

Caesarean section is rarely needed to be done when the foetus is already dead.

Vaginal prostaglandin and an oxytocin (Syntocin®) infusion are not needed and unlikely to be required.

Ultrasound examination to confirm the diagnosis and fetal death is also unnecessary given the clinical and Doppler findings.

Depot medroxyprogesterone acetate and the combination contraceptive vaginal ring are the most effective hormonal contraceptives for obese women because they do not appear to be affected by body weight. Women using the combination contraceptive patch who weight 90 kg may experience decreased contraceptive efficacy. Obese women using oral contraceptives may also have an increased risk of pregnancy.

The Sella turcica is composed of three parts:
1. The tuberculum sellae (horn of saddle): a variable slight to prominent median elevation forming the posterior
boundary of the prechiasmatic sulcus and the anterior boundary of the hypophysial fossa.
2. The hypophysial fossa (pituitary fossa): a median depression (seat of saddle) in the body of the sphenoid that accommodates the pituitary gland (L. hypophysis).
3. The dorsum sellae (back of saddle): a square plate of bone projecting superiorly from the body of the sphenoid.
It forms the posterior boundary of the Sella turcica, and its prominent superolateral angles make up the posterior clinoid processes.

Patient’s presentation and physical examination findings are most consistent with physiologic dyspnea, which is common during pregnancy. This breathing difficulty which is due to an increase in the tidal volume of lung will present itself as an increased awareness of breathing and can occur as early as the end of first trimester. Any minute increase in the ventilation occurs during pregnancy can make patients feel as if they are hyperventilating and contribute to the feeling of dyspnea.

Patient should be reassured and educated regarding these normal changes of pregnancy, also should be counselled to modify her exercise regimen accordingly to her changed tolerance.

Systolic ejection murmurs are due to increased blood flow across the aortic and pulmonic valves which is a normal finding in a pregnancy. So there is no need for this patient to be referred to a cardiologist or to order an ECG.
About 1 in 6400 pregnancies present with pulmonary embolism and there will be clinical evidence of DVT in many of these cases. Dyspnea, chest pain, apprehension, cough, hemoptysis, and tachycardia are the most common symptoms of PE and physical examination shows accentuated pulmonic closure sound, rales, or a friction rub. If there is a strong suspicion for PE, the patient should be followed up with a ventilation-perfusion scan, which will confirm PE if presented with large perfusion defects and ventilation mismatches.

Nerve Supply: L5 to S2 via Nerve to Piriformis
Origin: Sacrum
Insertion: Greater trochanter
Action: External rotation of hip
Blood Supply: Superior and Inferior gluteal arteries and lateral sacral arteries

An underlying disease is only found in 17 % of cases in mild polyhydramnios. In contrast, an underlying disease is detected in 91 % of cases in moderate to severe polyhydramnios. The literature lists the following potential aetiologies: fetal malformations and genetic anomalies (8–45 %), maternal diabetes mellitus (5–26 %), multiple pregnancies (8–10 %), fetal anaemia (1–11 %), other causes, e.g. viral infections, Bartter syndrome, neuromuscular disorders, maternal hypercalcemia. Viral infections which can lead to polyhydramnios include parvovirus B19, rubella, and cytomegalovirus. Other infections, e.g. toxoplasmosis and syphilis, can also cause polyhydramnios.

Second-trimester ultrasound markers have low sensitivity and specificity for detecting Down syndrome, especially in a low-risk population.

The highest detection rate is acquired with ultrasound markers combined with gross anomalies. Although the detection rate with this combination of markers is high in a high-risk population (50 to 75 percent), false-positive rates are also high (22 percent for a 100 percent Down syndrome detection rate).

Anaemia in pregnancy is defined by the British Committee for Standards in Haematology (BCSH) guidance: 1st trimester Hb < 110 g/l 2nd and 3rd trimester Hb < 105 g/l Postpartum Hb less than 100 g/l

Patients with a threatened abortion should be managed expectantly until their symptoms resolve. Patients should be monitored for progression to an inevitable, incomplete, or complete abortion. Analgesia will help relieve pain from cramping. Bed rest has not been shown to improve outcomes but commonly is recommended. Physical activity precautions and abstinence from sexual intercourse are also commonly advised. Repeat pelvic ultrasound weekly until a viable pregnancy is confirmed or excluded. A miscarriage cannot be avoided or prevented, and the patients should be educated as such. Intercourse and tampons should be avoided to decrease the chance of infection. A warning should be given to the patient to return to the emergency department if there is heavy bleeding or if the patient is experiencing light-headedness or dizziness. Heavy bleeding is defined as more than one pad per hour for six hours. The patient should also be given instructions to return if they experience increased pain or fever. All patients with vaginal bleeding who are Rh-negative should be treated with Rhogam. Because the total fetal blood volume in less than 4.2 mL at 12 weeks, the likelihood of fetal blood mixture is small in the first trimester. A smaller RhoGAM dose can be considered in the first trimester. A dose of 50 micrograms to 150 micrograms has been recommended. A full dose can also be used. Rhogam should ideally be administered before discharge. However, it can also be administered by the patient’s obstetrician within 72 hours if the vaginal bleeding has been present for several days or weeks.

Women with a bicornuate uterus are at increased risk of recurrent abortions, premature birth, fetal malpositioning, placenta previa and retained products of placenta leading to post partum haemorrhage.

Anaemia in pregnancy is most frequently caused by iron or folate deficiency, however, a wide variety of other causes may be considered, especially if the haemoglobin value is below 9.0 g/dL. A haemoglobin level of 11 g/dL or more is considered normal early in pregnancy, with the upper limit of the ‘normal range’ dropping to 10.5 g/dL by 28 weeks gestation. Haemoglobin < 10.5 g/dl in the antenatal period, one should exclude haemoglobinopathies and consider haematinic deficiency. Oral iron is 1st line treatment for iron deficiency. Anaemia not due to haematinic deficiency will not respond to any form of iron. This should be managed with transfusion

Fat necrosis is often a result of a trauma or surgery. In fat necrosis the enzyme lipase releases fatty acids from triglycerides. The fatty acids combine with calcium to form soaps. These soaps appear as white chalky deposits which are firm lumps with no associated discharge. The given case has a bruise which indicates prior trauma.

Heparin is a large-sized molecule and does not cross the placenta; it can provide anticoagulation in the mother, however, has no effect on the baby. Heparin is the preferred anticoagulant therapy during pregnancy.
Moreover, the anticoagulant effect of heparin can be rapidly reversed by protamine sulphate.
Warfarin, a coumarin derivative, takes much longer to be reversed compared to heparin. This can be given to the mother between 13 and 36 weeks of pregnancy, however, should be avoided in the first trimester due to its teratogenic effects.
The anticoagulant effect of coumarin derivatives on the baby also takes longer to be reversed.

According to NICE guidelines women with type I diabetes, who are expecting a child should aim to keep their HbA1c level[1] below 48 mmol/mol (6.5%) without causing problematic hypoglycaemia. Women with diabetes whose HbA1c level is above 86 mmol/mol (10%) should be strongly advised not to get pregnant because of the associated risks. The risks are higher with chronic diabetes. There is an increased risk to the foetus or mother due to diabetes in pregnancy. Women who are waiting to become pregnant should take folic acid (5 mg/day) until 12 weeks of gestation to reduce the risk of having a baby with a neural tube defect.

Bacterial vaginosis (BV) is a common infection of the vagina caused by the overgrowth of atypical bacteria, most commonly Gardnerella vaginalis, a gram-negative rod. In diagnosing BV, a swab is taken for microscopy, often revealing clue cells. Clue cells are cells of the vaginal epithelium which are covered by adherent Gardnerella, giving them a distinctive look under the microscope. Though many are asymptomatic, some infected women complain of a greyish, foul-smelling vaginal discharge. Their vaginal fluid pH may also become more alkaline. BV does not however present with pyrexia, so the lady’s fever could be attributed to another cause as she is still a patient on the medical ward.

During pregnancy cardiac output increases by 30 to 50%. As a result, the resting pulse speeds up from a normal of about 70 bpm to 80 or 90 bpm.